Access, Bottlenecks, Costs, and Equity (ABCE):Understanding the costs of and constraints to health service delivery in Uganda

On behalf of the ABCE research teamInstitute for Health Metrics and Evaluation | Infectious Diseases Research Collaboration

January 2015

Overview

• Overview of the ABCE project in Uganda

• Key findingso Facility capacity and service provision

o Non-HIV patient perspectives

o Efficiency and costs of care

o A focus on HIV: service provision and patient characteristics

o Results from the Viral Load Pilot Study

• Using ABCE work and findings for policymaking

• Conclusions

Overview of the ABCE project in Uganda

Overview of the ABCE project in UgandaABCE study design and implementation

• Collaboration between IDRC and IHME

• Primary data collection took place in two phases:o April – October 2012

o April – August 2013

• Four main data-collection mechanisms:o ABCE Facility Survey

o Clinical chart extractions of HIV-positive patients on ART

o Patient Exit Interview Survey

o Biological samples for the Viral Load Pilot Study

Overview of the ABCE project in UgandaABCE Facility Survey

• Primary data collection from a nationally representative sample of 247 facilities

• Collected data on a full range of indicatorso Inputs, finances, outputs, supply-side

constraints and bottlenecks, indicators for HIV care

• Randomly sampled a full range of facility typeso National and regional referral

hospitals, district hospitals, health centers, clinics, drug stores or pharmacies, and DHTs

Overview of the ABCE project in UgandaClinical chart extraction

• Extracted data on HIV-positive patients currently enrolled in ART

• Chart data included patient demographic information, ART initiation characteristics (e.g., CD4 cell count, WHO stage, drug regimen, referral points), and patient outcomes

Overview of the ABCE project in UgandaPatient Exit Interview Survey

• Over 3,900 structured interviews were conducted with patients after they exited facilities from the ABCE sample.

• Interviewees include patients who sought HIV care and those who presented at facilities for non-HIV services.

• Questions included reasons for the facility visit, satisfaction with services, expenses paid associated with the facility visit, and HIV-specific indicators.

Overview of the ABCE project in UgandaViral Load Pilot Study

• Included 15 facilities within the ABCE sample.

• Compared measures of patient viral load (VL) assessed by plasma and dried blood spots (DBS).

• Also collected concurrent measures of CD4 cell counts.

• Collected data from patients who had been on ART between 6 and 60 months from 15 facilities in the ABCE sample.

Key findings from the ABCE project in UgandaFacility capacity and service provision

Facility capacity and service provisionAvailability of health services in 2012

• Relatively high availability of key services across platforms, especially among public or NGO-owned facilities.o 94% had a formal immunization program

o 85% offered antenatal care (ANC)

o 83% provided family planning options

o 72% had HIV/AIDS care

o 93% stocked ACTs for treating malaria

• Other services remained fairly scarce, particularly at lower levels of care.o e.g., emergency services were available at 73% of district hospitals, 42%

of health center IVs, and 28% of health center IIIs

Facility capacity and service provisionGaps in reported and functional capacity for care, 2012

• Many facilities reported providing a given service, but then lacked the full capacity to provide that service (e.g., lacking functional equipment or stocking out of medications).

ServiceFacilities reporting

capacityFacilities with

functional capacity

Antenatal care 78% 13%

General surgery services

24% 5%

Facility capacity and service provisionGaps in reported and functional capacity for ANC

• Sulfadoxine/pyrimethamine (SP) was widely available across platforms for IPTp.

• Outside of hospitals, few facilities had the capacity to perform important tests for ANC (e.g., Rh factor, blood glucose).

• Less than 20% of health centers had ultrasound.

• District hospitals had the smallest discrepancy in reported and functional capacity (100% reported providing ANC, 73% were fully equipped to provide ANC).

• Health center IVs and health center IIIs had the widest discrepancy (96% reported providing ANC, less than 5% were fully equipped).

Facility capacity and service provisionGaps in reported and functional capacity for ANC, 2012

Facility capacity and service provisionAvailability of and deficiencies in physical capital

• Power supplyo All hospitals were connected to the energy grid, whereas 30% of health

center IIIs and 66% of health center IIs lacked access to the energy grid.o Just over 50% of facilities that had access to the energy grid also had a

generator.

• Water and sanitationo Nearly all hospitals had piped water and sewer infrastructure (flush

toilets).o The majority of health centers had at least a covered pit latrine and an

improved water source; however, it was less than the 2010 MOH target.

• Transportation and communicationo The majority of primary care facilities lacked emergency transportation

and did not have access to a facility-based phone.

Facility capacity and service provisionAvailability of and deficiencies in physical capital, 2012

Facility capacity and service provisionAvailability of equipment across platforms

• Individual types of equipmento Hospitals had a greater availability of most functional equipment than

primary care facilities.

o Relatively basic equipment, such as glucometers and ultrasound, was generally available among 20% of health centers.

• Full stocks of medical equipment for levels of care o Applied the WHO Service Availability and Readiness Assessment (SARA)

survey standards for a subset of equipment and their availability.

o Hospitals generally had a higher availability of equipment recommended for their level of care than primary care facilities.

Facility capacity and service provisionAvailability of recommended equipment for level of care, 2012

Based on a subset of items from the WHO SARA survey

Facility capacity and service provisionAvailability of pharmaceuticals across platforms

• Based on the 2012 Essential Medicines List (EML), most facilities had at least 50% of the pharmaceuticals recommended for their level of care.

• Stocking of EML pharmaceuticals ranged within platforms, especially health center IIIs and health center IIs.

• Most commonly missing pharmaceuticals:o Key contraceptive medications

o Opiate pain medications

o Medications to treat NCDs

Facility capacity and service provisionAvailability of recommended pharmaceuticals for level of care, 2012

Based on the 2012 EML list

Facility capacity and service provisionCapacity for disease-specific case management

• Assessed the proportion of medical equipment, tests, and pharmaceuticals available to manage a subset of conditions that cause large disease burden in Uganda.

• Identified diseases based on the Global Burden of Disease 2010 study (GBD 2010):o Infectious diseases: lower respiratory infections (LRIs), HIV/AIDS, malaria,

meningitiso Non-communicable diseases (NCDs) and injuries: diabetes, injuries,

ischemic heart disease

• Facilities had the greatest capacity to diagnose and treat LRIs, HIV/AIDS, and malaria, but this capacity declined with levels of care.

• Facilities were least equipped to manage NCDs, especially among health centers.

Facility capacity and service provisionCapacity for disease-specific case management, 2012

Facility capacity and service provisionVaccine storage temperature for immunization services

• Of the facilities that routinely stored vaccines, 8% had refrigerators operating outside of the optimal range (2°C to 8°C).

• A greater proportion of facilities had storage temperatures below the optimal range (5%) than above (3%).

• Health center IIs had the greatest proportion of storage temperatures below 2°C or above 8°C (14%).

• All health center IIIs and health center IIs with improper temperature readings lacked functional electricity.

Facility capacity for service provisionVaccine storage temperature for immunization services, 2012

Facility capacity and service provisionCapacity to test for and treat malaria

• 93% of all facilities, including pharmacies, stocked artemisinin-combination therapies (ACTs) at the time of facility visit.

• 91% of publicly owned facilities had either rapid diagnostic tests (RDTs) or a microscope to test for malaria.

• All referral and district hospitals had the concurrent availability of ACTs and RDTs; 95% of health center IVs and 85% of health center IIIs had both.

• Demonstrates a successful uptake of Uganda’s policy for parasitological confirmation of malaria in the public sector.• Private and NGO-owned facilities showed a lower availability of malaria

testing than their public equivalents.

Facility capacity for service provisionCapacity to test for and treat malaria, 2012

Facility capacity and service provisionHuman resources for health

• Nurses accounted for the largest proportion of staff personnel across platforms, ranging from 33% at private hospitals to 57% at district hospitals.

• On average, 71% of personnel were considered skilled medical staff.

• Seven facilities – one district hospital and six health center IIIs –achieved the staffing goals outlined by the HSSP II.

• There was no direct relationship between facility staffing and urbanicity; however, far fewer rural health center IVs met the staffing goal for nurses.

Facility capacity and service provisionHuman resources for health: district hospitals, 2012

Facility capacity and service provisionHuman resources for health: health center IVs, 2012

Facility capacity and service provisionOutputs, 2007-2011

• Outpatient visits remained relatively stable over time across facilities.o The clear exception was referral hospitals, at which an average 11% annual

gain in outpatient visits occurred between 2007 and 2011.

• Inpatient visits were fairly consistent between 2007 and 2011.o Referral hospitals were the exception, with average inpatient visits

increasing 4% annually during this time.

• ART visits rapidly rose at a subset of platforms from 2007 to 2011.o There was a 115% increase across all facilities.

o Largely driven by referral hospitals, recording an average of 64,620 ART visits in 2011.

o Health center IVs and health center IIIs also had a large rise, but their relative patient volumes were much smaller than other platforms.

Facility capacity and service provisionOutputs: average outpatient visits, by platform, 2007-2011

Facility capacity and service provisionOutputs: average inpatient visits, by platform, 2007-2011

Facility capacity and service provisionOutputs: average ART visits, by platform, 2007-2011

Key findings from the ABCE project in UgandaNon-HIV patient perspectives

Non-HIV patient perspectives Patient reports of expenses associated with facility visit

• As part of the Patient Exit Interview Survey, patients who did not seek HIV services reported the types of expenses they had in association with the facility visit.

• Ugandan policies abolished user fees for health centers and general wings of public hospitals in 2001.

• Based on the ABCE sample, very few patients (3%) reported any medical expenses associated with visits to public facilities.o By contrast, 82% of patients seeking care at private facilities had

medical expenses.

Non-HIV patient perspectives Patient reports of expenses associated with facility visit, 2012

Non-HIV patient perspectives Levels of patient medical expenses

• Of patients who had medical expenses at public facilities, 75% spent less than 10,000 Ushs ($4).

• By contrast, many patients spent at least 20,000 Ushs ($8) in medical expenses at private facilities.

Non-HIV patient perspectives Levels of patient medical expenses, by facility, 2012

Non-HIV patient perspectives Patient wait times at facilities

• Just over half of patients reported less than an hour waiting for care, whereas 49% of patients had to wait at least an hour before seeing a provider

• At referral hospitals, 40% of patients spent more than two hours waiting for care. At private hospitals, 45% of patients received care within 30 minutes.

• Among health centers, a greater proportion of patients received care within an hour with descending levels of care.

Non-HIV patient perspectives Patient reports of wait times at facilities, by platform, 2012

Non-HIV patient perspectives Patient ratings of facilities

• Overall, patients gave high ratings for care received across platforms.

• Patients rated staff interactions highly, especially for medical provider respectfulness.

• Patients generally gave lower ratings to facility characteristics, particularly for spaciousness and wait time.

Non-HIV patient perspectives Patient overall ratings of facilities, by platform, 2012

Non-HIV patient perspectives Average patient ratings of facility indicators, by platform, 2012

Key findings from the ABCE project in UgandaEfficiency and costs of care

Efficiency and costs of careEstimating efficiency: Data Envelopment Analysis (DEA)

• DEA: quantifies the relationship between a facility’s resources (medical staff, beds) and its production of services (outpatient visits, inpatient bed-days, births, and ART visits) relative to comparably sized facilities in the ABCE sample.

• Efficiency score: a value between 0% and 100%, reflecting the alignment of facility resources to service production.o 100% = maximum use of facility resources for output production

• Outpatient equivalent visits (OEV): weighting different outputs in a standardized way to allow for direct comparisons across facilities.o Average across facilities:

Inpatient bed-day = 3.7 outpatient visits Birth = 10.5 outpatient visits ART visit = 1.7 outpatient visits

Efficiency and costs of careAverage production of outputs across facilities

• Across platforms, facilities averaged a total of five outpatient equivalent visits per medical staff per day, ranging from 4.3 visits at health center IIs to 7.0 visits at clinics.

• Outpatient visits accounted for the largest proportion of patient visits experienced per medical staff per day at primary care facilities and private hospitals.

• Inpatient bed-days accounted for the largest proportion of patient visits produced per medical staff per day at referral and district hospitals.

• Private hospitals recorded the largest volume of ART visits per medical staff per day (1.7, as measured in OEV).

Efficiency and costs of careAverage production of outputs across facilities, 2011

Note: All visits are in outpatient equivalent visits, with an average of one inpatient bed-day equaling 3.7 outpatient visits; one birth equaling 10.5 outpatient visits; and one ART visit equaling 1.7 outpatient visits.

Efficiency and costs of careEfficiency scores varied across and within platforms

• Across all facilities, the average efficiency score was 31%.

• Over half of facilities had an efficiency score at or less than 30%.

• Average efficiency scores declined in parallel with decreasing levels of care among public facilities.

• Tremendous range in efficiency scores within platforms:o At least one facility had an efficiency score of 100% for each platform.o Multiple facilities had efficiency scores close to 0% for each facility type.

• No consistent relationship between urbanicity and efficiency scores:o Urban hospitals generally had higher efficiency scores than rural hospitals.o Rural health centers generally had higher efficiency scores than urban

health centers.

Efficiency and costs of careEfficiency scores across platforms, 2007-2011

Efficiency and costs of careEstimated potential for expanded service production

• We estimated that facilities had substantial potential for increasing output production, especially among lower levels of care.

• An average of 16 additional visits, measured in OEV, could be added across facilities, based on observed resources.

• This potential for expanded service production does not reflect the quality of services delivered; it shows the alignment of facility resources and output production.

Efficiency and costs of careEstimated potential for expanded service production, 2011

Efficiency and costs of careCross-country comparison of efficiency

• Uganda showed more potential for expanded service provision, given observed resources, than Kenya and Zambia.

Efficiency and costs of careEstimating costs of care

• Using information produced through DEA, output-specific spending by facilities was divided by outputs produced by each facility.

• All cost data were adjusted for inflation and reported in 2011 Ugandan shillings (Ushs). o All US dollar estimates were based on the 2011 exchange rate of 2,500

Ushs per $1.

Efficiency and costs of careAverage facility cost per visit, across outputs and by platform

• Facility costs per patient visit varied across platforms and by output type.

• The average facility cost per outpatient visit was generally the least expensive to produce, and births were the most expensive.

• Private hospitals generally spent the most per patient visit produced, whereas health center IIIs generally produced patient visits at the lowest facility cost per output.

Efficiency and costs of careAverage facility cost per visit, across outputs and by platform

Efficiency and costs of careCross-country comparison of output costs

• Ugandan facilities averaged the least expensive production cost per outpatient visit and ART visit (excluding the cost of ARVs).

Key findings from the ABCE project in UgandaA focus on HIV: service provision and patient characteristics

HIV service provision and patient characteristicsART regimen at initiation, 2008-2012

• From 2008 to 2012, there was a rapid transition away from d4T-based ART regimens toward those with a TDF backbone for ART initiates.

• In 2008, 9% of ART patients initiated on TDF. In 2012, 59% did.

• TDF prescription rates varied across facilities, from 2% to 85% in 2011 and 2012. o Health centers generally had a slightly lower proportion of ART patients

initiating on TDF-based regimens than hospitals in 2011 and 2012.

HIV service provision and patient characteristicsART regimen at initiation, 2008-2012

HIV service provision and patient characteristicsART regimen at initiation, by facility, 2011-2012

HIV service provision and patient characteristicsPatient clinical characteristics at ART initiation: WHO staging

• There was a steady shift toward ART initiation at earlier stages of disease progression between 2008 and 2012.

• In 2008, 51% of patients initiated at WHO stage 1 or 2. In 2012, 72% began treatment at the same stages.

• There was substantial heterogeneity in ART initiation by WHO stage across facilities in 2011 and 2012.o In general, hospitals saw a greater proportion of ART patients starting

therapy at WHO stage 1 than health centers.

HIV service provision and patient characteristicsWHO stage at initiation, 2008-2012

HIV service provision and patient characteristicsWHO stage at initiation, by facility, 2008-2012

HIV service provision and patient characteristicsPatient clinical characteristics at ART initiation: CD4 cell count

• A greater proportion of ART patients began therapy at higher CD4 cell counts in 2012 than in 2008.o In 2008, 35% of patients initiated at a CD4 cell count of 200 cells/mm3

or higher. In 2012, 54% of patients initiated at this level of CD4.

• Median CD4 cell count increased 62%, from 139 cells/mm3 in 2008 to 225 cells/mm3 in 2012.

• A substantial portion of ART patients still began therapy once they were symptomatic.o About 20% of patients initiated ART with a CD4 cell count less than 50

cells/mm3 from 2008 to 2012.

HIV service provision and patient characteristicsCD4 cell count at initiation, 2008-2012

HIV service provision and patient characteristicsFacility availability of patient clinical information

• Testing rates have remained stable over time, indicating that record-keeping has increased in parallel with rising ART patient volumes.

• In 2012, a portion of ART initiates still did not receive key tests.o 17% lacked a CD4 cell count

o 10% were not assigned a WHO stage

o 6% did not have a weight measurement

o 81% did not have a height measurement

• Follow-up measures were relatively infrequent, especially in comparison with Ugandan guidelines.

HIV service provision and patient characteristicsFacility availability of patient clinical information

HIV service provision and patient characteristicsART patient reports of expenses associated with visit, 2012

• As part of the Patient Exit Interview Survey, patients who sought HIV services reported the types of expenses they had in association with their facility visits.

• Ugandan national policy stipulated that ART care should be free at public facilities in 2003.

• Based on the ABCE sample, very few ART patients (< 2%) reported any medical expenses associated with visits to public facilities.o By contrast, 45% of ART patients seeking care at private facilities had

medical expenses.

• More than 50% of ART patients experienced some kind of transportation expense, especially at private hospitals (64%).

HIV service provision and patient characteristicsART patient reports of expenses associated with visit, 2012

ART patient perspectives ART patient reports of wait times at facilities

• Overall, ART patients reported relatively long wait times at facilities and often spent more time waiting than non-HIV patients at similar facilities.

• This was consistently found across platforms:o Health center IIIs

54% of ART patients waited more than two hours

25% of non-HIV patients waited more than two hours

o Private hospitals 41% of ART patients received care within one hour

70% of non-HIV patients received care within one hour

ART patient perspectives ART wait times at facilities, by platform, 2012

ART patient perspectives ART patient ratings of facilities

• Overall, ART patients gave high ratings for care received across platforms.o Nearly 70% of ART patients gave at least a rating of 8 out of a possible 10.

• ART patients generally gave higher ratings, across facility indicators, than non-HIV patients – except for wait time.

• Like non-HIV patients, ART patients rated staff interactions highly, especially for medical provider respectfulness.

• ART patients gave fairly high ratings of facility cleanliness and privacy, but rated wait time very poorly – especially at health center IIIs.

ART patient perspectives ART patient overall ratings of facilities, by platform, 2012

ART patient perspectives Average ART patient ratings of facility indicators, by platform, 2012

HIV service provision and patient characteristicsEfficiency scores for facilities providing ART

• Across facilities with ART, the average efficiency score was 49%.

• ART facilities typically had higher levels of efficiency, compared to all facilities in the ABCE sample.

• Potential to expand ART patient volumes, especially among health center IVs.

HIV service provision and patient characteristicsEfficiency scores for facilities providing ART

HIV service provision and patient characteristicsEstimated potential for increased ART visits given resources

• We estimated that many facilities had potential for increasing annual ART visits.

• Given observed facility resources, we estimated that an average of 6,367 additional ART visits could be added, per facility, each year.

• This gain represents a 55% increase in ART visits from the average annual ART visits observed in 2011 (11,632 ART visits).

HIV service provision and patient characteristicsEstimated potential for increased ART visits given resources

HIV service provision and patient characteristicsCross-country comparison of ART efficiency

• Uganda showed potential for expanded ART provision, given observed resources, but at a lesser magnitude than Kenya and Zambia.

HIV service provision and patient characteristicsProjected facility ART costs: analytical approach

• Four streams of data were used to project ART costs1. Average facility cost per ART visit, excluding ARVs, based on the ABCE

sample2. Average number of annual visits observed for new and established ART

patients in 2011, as extracted from clinical charts3. The ARV regimens of ART patients in 2011 extracted from clinical charts4. The ceiling ARV prices for 2011 published by the Clinton Health Access

Initiative (CHAI)

• Analytical steps for projecting ART costs1. Visit costs: multiplied average facility cost per ART visit, excluding ARVs, by

the average number of annual visits observed for new and established ART patients in 2011.

2. Total costs: using the relative proportion of TDF-, d4T-, and AZT-based regimens observed for patients, applied the ceiling price for each ARV, and added projected ARV costs to estimated visit costs.

HIV service provision and patient characteristicsProjected facility ART costs, 2011

• ARVs accounted for a large portion of projected annual facility costs for ART, but varied across patient types and platforms.o New patients

ARVs accounted for 47% of total projected ART costs to private hospitals

ARVs accounted for 78% of total projected ART costs at health center IVs

o Established patients ARVs accounted for 53% of total projected ART costs to private hospitals

ARVs accounted for 82% of total projected ART costs at health center IIIs

• Facility costs for ARVs may be viewed as more stable over time, whereas visit costs associated with ART services are likely to be lower for established patients.o Substantial implications for longer-term ART care and funding sources

HIV service provision and patient characteristicsProjected facility costs for ART, 2011

HIV service provision and patient characteristicsCross-country comparison of ART costs

• Ugandan facilities had ART costs comparable to those in Kenya, but much lower than those in Zambia.

• ARVs accounted for 72% of annual facility costs in Uganda, which was far more than Kenya (69%) and Zambia (60%).

Key findings from the ABCE project in UgandaA focus on HIV: results from the Viral Load Pilot Study

Results from the Viral Load Pilot StudyPatient viral load suppression across facilities

• The vast majority of ART patients (87%) showed successful viral load suppression (< 1,000 copies VL).

• All facilities in the Viral Load Pilot Study had viral suppression rates exceeding 75%, but these ranged from 76% to 96%.

• We did not find a significant correlation between average rates of viral load suppression and facility-level retention rates.

Results from the Viral Load Pilot StudyPatient viral load suppression across facilities, 2013

Results from the Viral Load Pilot StudyPatient viral load suppression and current CD4 cell count

• Rates of viral load suppression were highly correlated with the concurrent measure of CD4, but not to CD4 measures at ART initiation.

• CD4 cell counts did not ideally predict viral load suppression.o 27% of ART patients had a CD4 cell count less than 100 cells/mm3 but a

viral load less than 1,000 copies.

o 6% of ART patients had a CD4 cell count of at least 350 cells/mm3 but had a viral load exceeding 1,000 copies.

• CD4 cell count is a better measure of patient outcomes than solely clinical measures, but its use for assessing treatment response is inferior to using measures of viral load.

Results from the Viral Load Pilot StudyPatient viral load suppression by CD4 cell count, 2013

Results from the Viral Load Pilot StudyUsing DBS to measure viral load

• Overall, DBS samples underestimated viral load for ART patients.

• The DBS assay used was not sensitive enough to detect treatment failure at the patient level.

• Further assay development and testing is needed before DBS is a viable substitute for plasma under routine conditions.

Using ABCE work and findings for policymaking

Using ABCE for policymakingIdentifying health system progress and challenges

• Provides policymakers with the evidence to pinpoint areas of success and for improvement as linked to national goals and priorities

• Enables direct comparisons across facility types and ownership, allowing policymakers to contrast facility capacity in the public sector with that of the private sector

• Supports the timely use of data to inform policy dialogueso e.g., considering whether DBS is a viable substitute for plasma

Using ABCE for policymakingABCE Uganda policy report

http://www.healthdata.org/dcpn/uganda

Conclusions

ConclusionsFacility capacity for service provision

• High availability of a subset of services reflects how Uganda has expanded service availability throughout the country.o Immunization, family planning, ANC, concurrent availability of malaria diagnostics

and treatment.

• Substantial gaps in reported capacity and full capacity to provide services found across all levels of care. o This was particularly pronounced among primary care facilities and for the

management of NCDs.

• Many more facilities had improved infrastructure, especially electricity and piped water, than what was found in past studies.

• Facilities had a moderately high availability of recommended equipment and pharmaceuticals, but stocks varied greatly within facility types

• Over 70% of facility employees were skilled medical staff. Urban facilities generally had higher levels of skilled medical personnel than rural facilities.

ConclusionsFacility production of health services

• Average patient volumes generally remained stable over time, with ART visits as the clear exception at most facilities.

• Shortages in human resources and facility overcrowding have been viewed as widespread; in the ABCE sample, most facilities averaged fewer than six visits per medical staff per day.

• Given observed facility resources, service production could be potentially increased by an additional 16 outpatient equivalent visits per day, on average, per facility

• Annual ART visits could potentially increase as well, but by a more moderate magnitude (a 55% gain).

ConclusionsFacility costs of care

• Average facility cost per patient visit differed substantially across platforms and types of visits.

• In comparison with a subset of other countries in the ABCE sample, average facility costs in Uganda were low per ART visit and per outpatient visit.

• On average, ARVs accounted for a large proportion of ART facility costs, but how much varied based on patient status (new or established).o Projected ART facility costs, including ARVs, were generally lower in

Uganda in comparison with Kenya and Zambia, but ARVs contributed to a larger portion of overall annual costs in Uganda (72%) than the other two countries (69% and 60%, respectively).

ConclusionsPatient perspectives

• Among public facilities, very few patients reported any medical expenses associated with their facility visit.o This reflects Uganda’s prioritization of removing cost barriers to health

services.

• In general, a large portion of patients spent more time waiting at facilities to receive care than the time they spent traveling to the facility.o Given average staffing observed across facilities and patients seen per

medical staff per day, it is unlikely that inadequate human resources are the main driver of these long wait times.

• Patients gave high ratings of facilities, especially ART patients. o Staff interactions were regularly rated higher than facility characteristicso Patients gave fairly low ratings of wait time, particularly ART patients.

ConclusionsFacility-based provision of ART services

• A rapid shift away from d4T-based ART regimens and toward TDF occurred throughout Uganda – a significant success.

• Steady progress took place for initiating ART patients at earlier stages of disease, for both WHO staging and CD4 cell counts.• However, a portion of patients still began treatment after becoming

symptomatic in 2012.

• Gradual improvements were made in collecting ART patient clinical data, but too few did not receive key measures and tests at initiation and during follow-up visits.o Greater investment in ART patient record-keeping and data collection

ought to be considered.

ConclusionsMeasures of viral load

• Among ART patients in the Viral Load Pilot Study, the vast majority showed successful viral load (VL) suppression.

• CD4 cell count measures did not consistently reflect VL suppression among ART patients, indicating that CD4 is an inferior indicator to VL for monitoring response to treatment.

• Currently available DBS assays are not sensitive enough to detect treatment failure, under routine conditions, at the patient level. o Plasma-based measures of VL should remain the optimal way to assess

patient responsiveness to ART until further DBS assay development and testing occur.

ConclusionsPriority considerations for future work

• Updated analyses across indicators to assess progress and identify areas that may require more investment.

• Targeting a broader set of facilities to capture a clearer picture of levels and trends in facility performance.

• Linking estimates of efficiency to quality of the services produced at facilities, as well as other factors. o e.g., expediency with which patients receive care, demand for increased services

• Updated analyses for ART patient characteristics at initiation, to determine more recent uptake of new eligibility guidelines.

• Generating estimates of cost-effectiveness based on facility delivery of services and costs of production, and linking to ongoing work on estimating trends in health outcomes and disease burden.

Thank you

http://www.healthdata.org/dcpn/uganda